Out of Network Contract Specialist-Remote

Summary of Job

Responsible for day-to-day operations for all activities related to out-of-network negotiations, such as negotiating pre- and post-service Single Case Agreements (SCAs) on claims authorized on behalf of EmblemHealth's network as well as out-of network Agreements. Act as a liaison and operate as a vital link between specific out-of-network Facility, Ancillary, Delegated and/or Professional providers and EmblemHealth as it relates to out-of-network Agreements.

Responsibilities

• Determine appropriate action on a case-by-case basis for out-of-network claims: analyze the costs vs. benefits for individual cases in order to provide a meaningful balance between costs to the company and members' well-being.
• Balance conflicting requests and obtain appropriate resolutions within EmblemHealth's guidelines.
• Contribute to corporate cost containment efforts by negotiating single case agreements on pre- and post-service claims for authorized services rendered by providers who are out of EmblemHealth's network.
• Partner with G&A for out-of-network providers: respond to appeals; analyze individual claims; prepare materials and negotiate to provide resolution for the appeal.
• Maintain detailed and accurate data for all SCAs for payment trend analysis and future contract negotiations.
• Provide information and recommendations that help to identify patterns and trends.
• Provide timely, useful, and accurate responses to internal and external requests (provider requests for Open Negotiation via IDR/NSA process, Grievance & Appeals team requests for details surrounding a case, Utilization/Care Management requests to initiate a Single Case Agreement and escalated claim inquiries related to a Single Case Agreement or Open Negotiation).
• Communicate with providers and internal departments to respond to inquiries in a timely, accurate, and professional manner with minimal direction from leadership.
• Analyze, research, and resolve complex claims inquiries pertaining to negotiated Single Case Agreements according to the line of business and members' benefit plan.
• Audit Single Case Agreement ensuring proper payments are made to satisfy Annual Internal Audit reviews.
• Participate in special projects related to out-of-network negotiations by coordinating with Provider Network Management, Grievance & Appeals and other departments.
• Support and assist Out of Network Negotiations Manager, in preparing monthly performance reports for senior management.

Qualifications

• Bachelor's degree.
• 3 - 5+ years of relevant, professional work experience, preferably in Claims (Required)
• Excellent customer service skills with a high degree of timely problem resolution (Required)
• Ability to work well with various Plan departments is instrumental in the effectiveness of the position (Required)
• Time management skills and flexibility to work on multiple projects/assignments simultaneously, with ability to change focus in a crisis situation. Willingness to assume diverse duties and challenges (Required)
• Strong communication skills (verbal, written, interpersonal, negotiation, interpretation); ability to ensure that requests are articulated and that problems are accurately represented for resolution (Required)
• Interpersonal skills to effectively maintain working relationships to get issues resolved or to obtain information through people, and to represent the Plan and the Department in a favorable light (Required)
• Ability to work effectively both independently and as part of a team (Required)
• Mathematical and analytical skills; and the ability to identify and interpret trends and patterns (Required)
• Ability to organize, prioritize, and effectively manage multiple tasks with conflicting/overlapping deadlines (Required)
• Proficiency with MS Office - Word, Excel, Access, PowerPoint, Outlook, Teams, SharePoint, etc. (Required)
• Ability to manage sensitive and confidential issues (Required)

Additional Information

• Requisition ID: 1000003356
• Hiring Range: $56,160-$99,360